Renal Transplant: Immunosuppression

Key points

• Kidney-transplant immunosuppression uses an induction phase around transplantation followed by long-term maintenance therapy; regimens are individualised according to rejection risk, adverse effects and transplant-centre protocols.
• Induction: a calcineurin inhibitor-based regimen may be combined with an induction antibody such as basiliximab in appropriate adults; higher-risk patients may receive rabbit anti-thymocyte globulin according to specialist protocols.
• Maintenance: current NICE-supported initial options include immediate-release tacrolimus + mycophenolate mofetil ; corticosteroids are commonly included in standard clinical regimens, while alternatives such as ciclosporin, mTOR inhibitors or belatacept are selected for specific circumstances.
• Acute rejection is not managed simply by 'adding steroids after more than one steroid-responsive episode'. Treatment depends on the type and severity of rejection and biopsy/immunological assessment; corticosteroid treatment is commonly used for acute T-cell-mediated rejection, with additional therapy for steroid-resistant/severe rejection under transplant-specialist care.
• Calcineurin-inhibitor toxicity is an important transplant complication; tacrolimus/ciclosporin require therapeutic-drug monitoring and can cause nephrotoxicity, hypertension, tremor and metabolic adverse effects.
• MRCP discriminator: tacrolimus + mycophenolate is a key modern maintenance combination; basiliximab is an induction option.
• Exam trap: acute rejection is not diagnosed or treated solely by the number of previous rejection episodes; transplant-specialist assessment and often biopsy are required.